John Harvard's Journal
The Talking Cure
For decades, insurers and risk-management departments have told doctors that if they make a mistake, the last thing they should do is admit it to the patient. But in the new millennium, national medical organizations have begun signing on to a simple but revolutionary idea: doctors should be allowed, and encouraged, to talk openly to patients even when harm occurs in the course of medical care. In 2001, the national accrediting body for hospitals began requiring written policies on disclosing such “adverse events” to patients. This gratifies Lucian L. Leape, an adjunct professor of health policy at Harvard School of Public Health (HSPH) and former pediatric surgeon who has spent nearly two decades trying to bring about a culture change in the way the medical community views mistakes by clinicians.
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Leape is one of the authors of “When Things Go Wrong,” a 2006 paper that recommends ways for dealing with adverse events. (He prefers that term to “medical errors” because patients may suffer harm from factors beyond a doctor’s control—for example, a previously undetected medication allergy—and such episodes can be just as traumatic as incidents in which the doctor was at fault.) Among the suggestions: that doctors talk to patients or their families within 24 hours of an event’s occurrence, if possible, and follow up later; that they accept responsibility and express regret; that the communication come from the doctor most involved in the patient’s care, not from an administrator; and that the hospital waive the patient’s bills and provide reimbursement for other expenses. To help hospitals flesh out their often terse written policies, the paper also suggests words for such difficult doctor-patient conversations: “We failed you.” “This shouldn’t have happened.” “We’re going to find out what happened and do everything we can to see to it that it doesn’t happen again.” The Harvard teaching hospitals endorsed the document unanimously; their malpractice insurer, as well as several of the hospitals, each sent a representative to the working group that wrote the paper.
It is hard to overestimate how ingrained the old way of doing things is in doctors’ psyches. “This is shameful to say, but in many circumstances, the advice was ‘Do not talk to the family at all’—period,” says Robert Truog, professor of medical ethics in the department of social medicine at Harvard Medical School (HMS). “You can imagine a physician or a nurse, who is feeling horrible about what’s just happened, being told by their attorneys not to have any communication. You can imagine, from the family’s side, how horrible it is to have had a relationship with the doctor or nurse, and to suddenly have that completely cut off. And yet that was standard practice until recently.”
Last year, Truog, who also directs the Institute for Professionalism and Ethical Practice (IPEP) at Children’s Hospital Boston, helped design a program that trains doctors to have conversations of the kind Leape advocates. Employees of Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital have gone through the training; Massachusetts General Hospital (MGH) employees will attend this spring. Truog and David Browning, an HMS lecturer on anaesthesia and senior scholar at IPEP, used a coaching model: at Beth Israel, for example, just 10 people were trained, but the nurse on duty as administrative clinical supervisor always knows how to reach them, and can select the one with expertise best suited to each situation. If it’s a surgery case, the hospital’s vice chair of surgery is one of the coaches; for nursing cases, the group also includes the nurse director of professional practice development.
The curriculum grew out of “Difficult Conversations,” a more all-encompassing program on doctor-patient communication that Truog and Browning had developed. Typically, young physicians and nurses learn how to deal with patients and families through trial and error, Truog says. “The damage that can be done there is just as real as the damage that can be done by not being adequately skilled at a procedure.”
Fittingly, the program extends simulation, a method used to teach doctors technical skills, to the interpersonal. In practicing a new surgical technique, doctors can operate on a computerized mannequin that evaluates their performance. In practicing conversations, they talk with actors who tell the doctors what they might have done better—and how the conversation felt from the patient’s side. After an adverse event, responders have a continuum of possible ways to explain what happened, notes Kenneth Sands, Beth Israel’s senior vice president for healthcare quality. “The communication could be ‘Your medication gave you a seizure,’ or ‘You were given the wrong medication; therefore, you had a seizure,’ or ‘You were given the wrong medication because the resident did not write the order clearly, and that’s what gave you a seizure.’”
It’s not enough to tell a patient, “There was a miscommunication,” Browning echoes; unless the doctor explains what kind of miscommunication, and between which parties, patients and families will feel the doctor is hiding something or underestimating their capacity to understand what’s going on. Truog says families who revisit the ICU years later typically don’t remember many medical aspects of the care, but have “vivid memories of what somebody said to them. Those memories could be very positive—exactly the right word when they needed to hear it—or searingly negative, creating anger that never goes away.”
Beyond merely tolerating such straightforward conversations, the Harvard hospitals’ medical malpractice insurer is funding the training program. Controlled Risk Insurance Company/Risk Management Foundation (CRICO/RMF), the self-insurance vehicle for the University’s teaching hospitals, has also produced a documentary, directed by Koplow-Tullis professor of general medicine and primary care Thomas L. Delbanco, that features interviews with victims of medical injuries and their families. Many of the sentiments expressed aren’t pleasant—“One doctor told me I had a 50 percent chance of living…and then he walked away,” one woman recalls—but the insurer uses it because “sometimes it’s hard to hear the voice,” says Robert Hanscom, the foundation’s vice president for loss prevention and safety. “You can only spend 10 minutes with this patient—gotta move on to the next one. Sometimes it’s hard to hear the patient say, ‘I need someone to talk to about this. This is a terrible outcome for me and my family.’”
Brigham and Women’s has instituted a Web-based reporting system for adverse events and near misses. Beth Israel now has mandatory reporting forms for adverse events, and recently added a section for recording details of the subsequent conversation. And MGH has added disclosure to the topics covered during the internal discussion that routinely follows each adverse event. Gregg Meyer, MGH’s senior vice president for quality and safety, says giving disclosure such official status tells employees, “Not only is disclosure something that’s permitted, it’s something we expect.”
Some proponents of open disclosure believe it will save money: if people find out what happened up front, the argument goes, they are less likely to sue. In one instance, five years after the University of Michigan hospital system adopted an open-disclosure policy, in 2001, the number of malpractice claims filed against the hospital system annually had declined more than 50 percent, and litigation costs decreased accordingly. But whether those results will hold true elsewhere is unclear. In a controversial paper published in Health Affairs last year, professors from HMS and HSPH, led by David Studdert, adjunct professor of law and public health, modeled what would happen if hospitals nationwide began practicing full disclosure. Even assuming the average amount paid out after a medical injury fell by 40 percent, they projected that the total spent on compensating patients would rise by about a quarter, from $5.6 billion to $7 billion a year, because the number of claims filed would nearly triple as more patients found out that they had been harmed.
That study’s conclusions sparked a firestorm, but the people implementing the new policies at Harvard’s teaching hospitals say questions of cost are beside the point. “This may save us money—I don’t know. It’s hard to say,” says Hanscom. “We did it because we recognized that we really had to support the physicians in their ability to do the right thing in their care of patients. We’ll see how the money plays out.”
As a self-insurance vehicle for teaching hospitals, rather than a commercial insurer, CRICO/RMF is uniquely situated to carry out such an idealistic reform. And the hospitals’ teaching status means they, too, are uniquely situated to try something untested. “You have a lot of turnover among trainees, and so you can quickly inculcate a new philosophy,” says Ken Sands of Beth Israel. HMS itself has incorporated adverse-event disclosure into its curriculum: first-year students view Delbanco’s documentary, and Leape’s papers on error prevention and disclosure are required reading for third-year students.
Leape and others are pushing for even more complete integration. After all, frank conversations aren’t just good for patients, they’re good for doctors, too: hospitals, including Brigham and Women’s, are creating peer-support programs to help staff members cope with stressful experiences. Leape has first-hand knowledge of adverse events’ psychic toll. Thirty years ago, when he was a practicing surgeon, an 18-month-old child died while in his care. She had a bleeding ulcer, and Leape says he waited too long to operate. He apologized to the child’s parents, but the incident left “an indelible impression.” When something like that happens, he says, “you remember it forever.”